Enucleation vs evisceration vs exenteration

1. Enucleation, Evisceration, Exenteration
Dr. Vinit Kumar
SCEH, Lahan , Nepal
O.A. 2nd year class

2. Enucleation : INTRODUCTION
• Enucleation is the surgical procedure that involves removal of the entire globe & its
intraocular contents, with preservation of all other periorbital and orbital structures.
• Enucleation is in contrast to evisceration, in which the ocular contents are removed
from an intact sclera .
• Exenteration, in which the entire orbital contents, including the globe & soft tissues,
are removed.
• The surgical removal of the eye was first reported in the 1500s as a procedure known
as extirpation.

4. Indications The following are indications for enucleation:
• 1. Absolute indications are retinoblastoma and malignant melanoma.
• 2. Relative indications are painful blind eye, nonresponsive to conservative measure
mutilating ocular injuries, non bleeding anterior staphyloma & phthisis bulbi
• 3. Indication for eye donation from cadaver is presently the most common
indication for enucleation , Research purpose (keratoplasty )
• Sympathetic ophthalmia
• Microphthalmos , trauma

5. Advantages
• In contrast to evisceration, enucleation allows for histologic examination of an
intact globe and optic nerve. This is particularly important in settings of biopsy-
proven or suspected intraocular malignancy, in which it is essential to determine
the margins of the malignancy & invasion of the optic nerve, if present .
• Enucleation classically has been thought to decrease the risk of sympathetic
ophthalmia as it avoids exposure to uveal antigens that may occur during an
evisceration. However, more recent studies have reported no cases of sympathetic
ophthalmia following evisceration .

6. Disadvantages
• A reduction in implant motility is often noted in enucleations . However, no
difference in prosthesis motility was noted between evisceration & enucleation
patients.
• Eighty-two percent (82 %) of survey respondents believed that evisceration afforded
the best ocular motility & best overall cosmetic outcome, & 94% percent believed
that complications of enophthalmos were more common after enucleations.

7. Complications (intraoperative)
• Removal of the wrong eye
• Damage to or loss of extraocular muscles
• Hemorrhage
• Perforation of eye

8. Postoperative complications
• Postoperative: Infection . Hemorrhage . Wound dehiscence
• Extrusion of the conformer .
• Contraction of the fornices
• Exposure of the implant & Extrusion / migration of the implant
• Ectropion
• Entropion
• poorly fitting prosthesis
• Enophthalmos
• Socket contracture

9. IMPLANTS
• Implants are made in distinct sizes, & intraoperative selection of the appropriately sized
implant is determined by the size of the patient’s orbit & the size of the implant
necessary to achieve symmetry with the fellow eye. Implants may be porous or
nonporous. Porous implants allow for anchoring of the extraocular muscles with
proliferation of fibrovascular tissues into the implant itself. These include
hydroxyapatite, porous polyethylene & proplast .
• These are cheaper than non porous .

10. Different types of orbital implant ( semiintegrated ,non integrated, bio
integrated , porous & non porous implant )

11. Surgical steps for enucleation

12. Surgical technique
• 1. Separation of conjunctiva & Tenon’s capsule
• 2. Separation of extraocular muscles
• 3. Cutting of optic nerve
• 4. Removal of eyeball
• 5. Inserting an orbital implant
• 6. Closure of conjunctiva and Tenon’s capsule
• 7. Fitting of artificial prosthetic eye Conformer may be used postoperatively so that
the conjuctival fornices are retained
• 8.deep prosthetic eye can be inserted for good cosmetic appearance after 6 wks

14. Postoperative Management
• Patching was done for a brief period postoperatively & instructed to return to clinic
one week after the surgery. Medicines like analgesics & antiemetics given.
• Once the conjunctiva closure has healed, generally about 4-8 weeks (after 2 months)
postoperatively, an ocular prosthetic fitting was prescribed .
• Regular follow up is required & to maintain the health of their socket is required .

15. • Nonporous implants do not allow for proliferation of tissues into the implant.
Therefore, they may have decreased motility and greater risk of implant migration.
• Types of nonporous implants include glass, silicone, acrylic, and
polymethylmethacrylate (PMMA).
• The rectus muscles still may be sutured over the implant to impart motility to the
implant and prosthesis, or suture to a wrapped material.

20. Evisceration : introduction
• Evisceration is a surgical technique by which all intraocular contents are removed
while preserving the remaining scleral shell, extraocular muscle attachments, &
surrounding orbital adnexa.
• The surgery often includes placement of an implant into the evisceration cavity
to maintain appropriate orbital volume.

21. Indications for evisceration :
• Indications
• Endophthalmitis
• Penetrating ocular trauma
• Blind, painful eye
• Panophthalmitis
• Contraindications
• Known or suspected intraocular malignancy
• Phthisis bulbi and microphthalmia (relative)

22. Surgical procedure technique

24. Evisceration & orbital implant & artificial eye insertion

25. Advantages of Evisceration over Enucleation
• Shorter operative time
• Less complex surgery
• More cost efficient
• Less disruption of orbital tissues
• Improved motility
• Less chance of spread of infection to nervous system
• Less painful

26. Disadvantages of Evisceration over Enucleation
• Risk of sympathetic ophthalmia
• Risk of dissemination of intraocular tumors

27. Complications of evisceration
• Retrobulbar hemorrhage
• Orbital edema
• Dissemination of unexpected intraocular neoplasm
• Implant exposure
• Implant extrusion
• Common post-operative care include the use of a dressing, pressure patch, and/or ice cold compresses to help
with post-operative edema and comfort.
• A temporary tarsorrhaphy can be used to help with conformer retention & early post-operative swelling

28. Orbital Exenteration Introduction
• Exenteration is a surgical procedure involving removal of the entire globe & its
surrounding structures including muscles, fat, nerves & eyelids
• Its extent is determined by disease being treated

29. Orbital Exenteration : indications
• Exenteration is performed mostly for orbital malignancies in an attempt to become
cure of cancer with tumor free margins.
• It is also performed in painful or life-threatening orbital infections or inflammations.
• Malignancies of the ocular adnexa are the most common causes of orbital
exenteration include squamous cell carcinoma, basal cell carcinoma, sebaceous
carcinoma with orbital extention & mucourmycosis .
• Other less common tumors include conjunctival malignant melanoma, adenoid cystic
carcinoma of the lacrimal gland & uveal melanoma with extrascleral extension.

30. Different types of orbital exenteration
1. Subtotal orbital exenteration = only the anterior orbital tissue is removed
2. Total = orbital contents are removed in total or complete
3. Radical = adjacent structures like paranasal sinuses are also sacrified
4. Extended = one or more orbital bones are removed
5. Other types :
LID SPARING ORBITAL EXENTERATION & TOTAL ORBITAL EXENTERATION

31. Different types of orbital exenteration
• Lid Sparing vs. Total Exenteration

32. Orbital exenteration

33. Complications of orbital exenteration
• extensive bleeding, which may rarely necessitate a blood transfusion
• ethmoid bones can be fractured during the surgery, leading to an opening between
the orbit and the nasal cavity
• CSF leaks can occur , Postoperative infection & wound leak
• Intracranial infections
• Obliteration of the cavity provides a protective barrier that protects the cranium
from a potential infection .
• obliterating the cavity in its entirety with soft-tissue free-flaps

34. HOME WORK
1. What is enucleation ? What are the indications for enucleation ?
2. What are the types of orbital implant ? Classification with one example of each ?
3. What are the complications after enucleation surgery ?
4. What is evisceration ? What are the contraindication for evisceration surgery ?
5. What are the indications for evisceration ?
6. Explain in brief different surgical steps for evisceration & enucleation surgery ?
7. What is orbital exenteration ?
8. What sre the different types of orbital exenteration ?
9. What are the indications for orbital exenteration ?

35. different types of ocular implant

36. CONSUMABLES & SURGICAL INSTRUMENTS
• GLOVES
• SYRINGES
• NEEDLE
• DRAPES
• ORBITAL IMPLANT
• SUTURE MATERIAL
• CONFORMER
• ARTIFICIAL / PROSTHETIC EYE

37. Surgical instruments

38. wire speculum, tenotomy scissor, muscle hook, suture material (4-0 mersilk, 6-0
vicrly), needle holder, tooth or fixation forcep, evisceration spoon,

39. Artificial customized prosthetic eye, conformer, orbital implant

40. HOME WORK
1. What is enucleation ? What are the indications for enucleation ?
2. What are the types of orbital implant ? Classification with one example of each ?
3. What are the complications after enucleation surgery ?
4. What is evisceration ? What are the contraindication for evisceration surgery ?
5. What are the indications for evisceration ?
6. Explain in brief different surgical steps for evisceration & enucleation surgery ?
7. What is orbital exenteration ?
8. What sre the different types of orbital exenteration ?
9. What are the indications for orbital exenteration ?

41. ThankYou